MEDICARE: ROBERT WAYNE MIMS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	21944	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00QH70	OTHER	TX	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1881777647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT WAYNE MIMS PH.D.

Provider Business Mailing Address
First Line	:	4646 CORONA DR
Second Line	:	SUITE 256
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78411-4320
Country	:	US
Telephone Number	:	361-853-2511
Fax Number	:	361-853-0074

Provider Business Practice Location Address
First Line	:	4646 CORONA DR
Second Line	:	SUITE 256
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78411-4320
Country	:	US
Telephone Number	:	361-853-2511
Fax Number	:	361-853-0074

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	07/08/2007

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